Dysphagia in the elderly

Late Dysphagia Following Radiotherapy After Nasopharyngeal Carcinoma: A Case Series

Purpose Standard treatment for nasopharyngeal carcinoma (NPC) is radiation therapy (RT); however, long-term effects of RT frequently include significant swallowing impairments (dysphagia; Gaziano, 2002; Hui, Chan, & Le, 2018). Our objective was to describe swallowing physiology in consecutive outpatients with a history of NPC following RT using standardized methods. Understanding dysphagia characteristics in this patient population could ultimately inform rehabilitation strategies and improve patient outcomes. Method We conducted a retrospective, observational, descriptive study of consecutive outpatients undergoing videofluoroscopic swallowing (VFS) exams at our clinic, from 2009 to 2014. We included those with a diagnosis of NPC treated with RT. Those with other cancer diagnoses; previous tracheostomy; acute neurological injury; and progressive, degenerative neurological conditions were excluded. Two registered MBSImP clinicians, blinded to each other, reviewed and scored the VFS exams according to previously published methods (Martin-Harris et al., 2008). Following unblinding, a single reviewer collected demographic data from the electronic medical record. We reported overall impairment and MBSImP component scores descriptively. Results Of 158 outpatients undergoing VFS, 6 (N) met our inclusion criteria. The median time from completion of RT to outpatient VFS was 21.0 years. Patients reported a variety of dysphagia symptoms. All patients had high oral and pharyngeal residue scores (scores ≥ 2) and high impairment scores on components contributing to bolus transport and airway closure. Conclusions All patients presented with impairments in oral-pharyngeal bolus transport and airway protection. Our results identify specific swallowing impairments for this patient group highlighting possible latent RT effects on swallowing. This population would benefit from dysphagia rehabilitation and maintenance programs informed by multimodal diagnostic approaches.

Tongue Force Training Induces Plasticity of the Lingual Motor Cortex in Young Adult and Aged Rats

Tongue exercise programs are used clinically for dysphagia in aged individuals and have been shown to improve lingual strength. However, the neural mechanisms of age-related decline in swallowing function and its association with lingual strength are not well understood. Using an established rat model of aging and tongue exercise, we hypothesized that the motor cortex of aged rats would have a smaller lingual motor map area than young adult rats and would increase in size as a function of tongue exercise. Over 8 weeks, rats either underwent a progressive resistance tongue exercise program (TE), learned the task but did not exercise (trained controls, TC), or were naïve untrained controls (UC). Cortical motor map areas for tongue and jaw were determined using intracortical microstimulation (ICMS). Rats in the TE and TC groups had a significantly larger motor cortex region for the tongue than the UC group. Lingual cortical motor area was not correlated with protrusive tongue force gains and did not differ significantly with age. These results suggest that learning a novel tongue force skill was sufficient to induce plasticity of the lingual motor cortex yet increasing tongue strength with progressive resistance exercise did not significantly expand the lingual motor area beyond the gains that occurred through the skilled learning component.

Predictive value of laryngeal adductor reflex testing in patients with dysphagia due to a cerebral vascular accident

Purpose: To determine the relationship between air pulse vs. touch laryngeal adductor reflex (LAR) tests and the clinical sensory findings of fiberoptic endoscopic evaluations of swallowing.Method: A retrospective review was conducted for 43 patients with dysphagia due to stroke that underwent fiberoptic endoscopic evaluation of swallowing with sensory testing (FEESST). Each patient received LAR testing using air pulse or touch methodologies. Clinically, responsiveness to pharyngeal residue and responsiveness to penetration or aspiration were analysed.Result: The sensitivity, specificity, positive and negative predictive values for both LAR test groups indicate that LAR testing did not effectively predict sensory function during the clinical swallow evaluation. Across both LAR groups, specificity values were higher than sensitivity values. In fact, the specificity values for the light touch LAR test group were extremely high, but the negative predictive values did not support those findings. Sensitivity and positive predictive values were low for both groups.Conclusion: Although LAR testing provides valuable information regarding laryngeal sensory discrimination, the results of the current study suggest that a clinical evaluation of swallowing is critical for effectively assessing the way in which patients utilise sensory information during swallowing.

Association Between Postextubation Dysphagia and Long-Term Mortality Among Critically Ill Older Adults

BACKGROUND

Dysphagia following extubation is common in intensive care unit (ICU) patients. Diagnosing postextubation dysphagia allows identification of patients who are at highest risk for aspiration and its associated adverse outcomes. Older adults are at an increased risk of postextubation dysphagia and its complications due to multiple comorbidities, a higher baseline risk of dysphagia, and increased risk of pneumonia.

OBJECTIVES

We aimed to investigate the association between postextubation dysphagia and 1-year mortality in older patients. Secondary outcomes included ICU and hospital lengths of stay, ICU readmission, and place of discharge.

METHODS

We performed a retrospective cohort study from January 1 to December 31, 2013. ICU patients, aged 65 years and older, who were successfully extubated and underwent a formal swallow evaluation by a speech and language pathologist (SLP) were included. Dysphagia was graded using a seven-point scale, and those with at least mild-moderate dysphagia were labeled as having clinically significant dysphagia.

RESULTS

Of 1075 patients who were screened, 359 were survivors, aged 65 years and older; and of these survivors, 111 had a swallow evaluation performed by an SLP after liberation from mechanical ventilation. Mean age was 73.8 years (SD = 7.0 years), and 41.4% had clinically significant dysphagia. In a multivariable regression model, there was no significant association between dysphagia and 1-year mortality. Furthermore, there was no statistically significant difference in ICU or hospital length of stay, ICU readmission, or place of discharge of those with clinically significant dysphagia compared to those without.

CONCLUSIONS

Among mechanically ventilated ICU patients, aged 65 years and older, who underwent a swallow evaluation following extubation, dysphagia was not associated with mortality, ICU and hospital lengths of stay, ICU readmission, and place of discharge. Given conflicting evidence in the literature, larger prospective studies are needed to clarify whether postextubation dysphagia is associated with worse outcomes in older patients admitted to the ICU. J Am Geriatr Soc 67:1895-1901, 2019.

Chronic radiation-associated dysphagia in oropharyngeal cancer survivors: Towards age-adjusted dose constraints for deglutitive muscles

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Age at treatment for OPSCC is a strong predictor of chronic radiation associated dysphagia (RAD).

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For swallowing regions of interest (ROIs), dose to ROI and age impact patients’ risk of chronic RAD.

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For patients at high risk for RAD more intense prophylactic swallowing therapies may be warranted.

Objectives

We sought to model chronic radiation-associated dysphagia (RAD) in patients given intensity-modulated radiation therapy (IMRT) for oropharyngeal squamous cell cancer (OPSCC) as a function of age and dose to non-target swallowing muscles.

Methods

We reviewed 300 patients with T1-T4 N0-3 M0 OPSCC given definitive IMRT with concurrent chemotherapy. Chronic RAD was defined as aspiration or stricture on videoflouroscopy/endoscopy, gastrostomy tube, or aspiration pneumonia at ≥12 months after IMRT. Doses to autosegmented regions of interest (ROIs; inferior, middle and superior constrictors, anterior and posterior digastrics, mylo/geniohyoid complex, intrinsic tongue, and gengioglossus) were obtained from DICOM-RT plans and dose-volume histograms. The probability of chronic RAD as a function of mean ROI dose, stratified by age (<50, 50–59, 60–69, or ≥70 years), was estimated with logistic probability models and subsequent unsupervised nonlinear curves.

Results

Chronic RAD was observed in 34 patients (11%). Age was a significant correlate of chronic RAD, both independently and with dose for all muscle groups examined. Distinct muscle-specific dose–response profiles were observed as a function of age (e.g., 5% of patients in their 50 s [but 20% of those 70 + ] who received 60 Gy to the superior constrictor had chronic RAD). This effect was stable across all observed muscle ROIs, with a false discovery rate-corrected p < 0.05, for all dose/muscle/age models, suggesting that including age as a covariate improves modeling of chronic RAD.

Conclusions

Age at treatment moderates the probability of chronic RAD after chemo-IMRT for OPSCC, with aging muscles showing lower dose thresholds. Uniform dose constraints may not predict toxicity in older patients.

Sarcopenia and swallowing disorders in older people

Aging is accompanied by several changes which may affect swallowing function. The beginning of these changes, termed presbyphagia, still captures a preserved swallowing function, although burdened by the consequences of the physiological aging process. Several stressors (including diseases and medications) can easily trigger the disruption of this (increasingly weak) equilibrium and lead to overt dysphagia. It is noteworthy that the swallowing dysfunction may be aggravated by the sarcopenic process, characterizing the so-called "sarcopenic dysphagia", potentially responsible for several health-related negative outcomes. The assessment and management of sarcopenic dysphagia largely rely on the evaluation and integrated treatment of both constituting conditions (i.e., sarcopenia and dysphagia). The management of dysphagia requires a multidimensional approach and can be designed as either compensatory (aimed at producing immediate benefit for the patient through postural adjustments, swallowing maneuvers, and diet modifications) or rehabilitative. Interestingly, some evidence suggests that resistance training traditionally applied to tackle the lower extremity in sarcopenia may be simultaneously beneficial for sarcopenic dysphagia. If these preliminary results (discussed in the present review article) will be confirmed, the systemic beneficial effects of physical exercise will be indirectly demonstrated. This will also support the need of promoting healthy lifestyle in all sarcopenic individuals (thus potentially at risk of dysphagia).

The Prediction of Risk of Penetration-Aspiration Via Hyoid Bone Displacement Features

Videofluoroscopic swallow studies are widely used in clinical and research settings to assess swallow function and to determine physiological impairments, diet recommendations, and treatment goals for people with dysphagia. Videofluoroscopy can be used to analyze biomechanical events of swallowing, including hyoid bone displacement, to differentiate between normal and disordered swallow functions. Previous research has found significant associations between hyoid bone displacement and penetration/aspiration during swallowing, but the predictive value of hyoid bone displacement during swallowing has not been explored. The primary objective of this study was to build a model based on aspects of hyoid bone displacement during swallowing to predict the extent of airway penetration or aspiration during swallowing. Aspects of hyoid bone displacement from 1433 swallows from patients referred for videofluoroscopy were analyzed to determine which aspects predicted risk of penetration and aspiration according to the Penetration-Aspiration Scale. A generalized estimating equation incorporating components of hyoid bone displacement and variables shown to impact penetration and aspiration (such as age, bolus volume, and viscosity) was used to evaluate penetration and aspiration risk. Results indicated that anterior-horizontal hyoid bone displacement was the only aspect of hyoid bone displacement predictive of penetration and aspiration risk. Further research should focus on improving the model performance by identifying additional physiological swallowing events that predict penetration and aspiration risk. The model built for this study, and future modified models, will be beneficial for clinicians to use in the assessment and treatment of people with dysphagia, and for potentially tracking improvement in hyolaryngeal excursion resulting from dysphagia treatment, thus mitigating adverse outcomes that can occur secondary to dysphagia.

Bolus Airway Invasion Observed During Videofluoroscopy in Healthy, Non-dysphagic Community-Dwelling Adults

OBJECTIVES

Typical aging may result in subclinical swallowing alterations (presbyphagia), which can place an individual at risk for dysphagia-related conditions, such as aspiration pneumonia, secondary to loss of functional reserve and rising incidence of age-related diseases associated with dysphagia. The purpose of this study was to investigate occurrence of airway invasion among healthy, nondysphagic community-dwelling adults. Further, we tested for differences of airway invasion across age categories and between sexes.

METHODS

Each eligible participant underwent a videofluoroscopic swallow study using a standardized approach of various volumes and viscosities. Ten swallows observed in the lateral viewing plane was assessed for observation of bolus airway invasion using the Penetration-Aspiration Scale (PAS) scoring system. Eligible participants (N = 195) were categorized according to 1 of 3 age categories (21-39 years, 40-59 years, 60 years and older) and sex (male, female) for analyses.

RESULTS

Out of 1936 swallows analyzed, we observed penetration in 113 swallows (5.8%) and aspiration in 6 swallows (0.3%). Majority (98%) of bolus airway invasion events occurred during the swallow. Mean or worst PAS scores did not significantly differ across age categories or between sexes. The odds ratios of PAS impairment between age categories did not reveal any significant differences. Males were more likely to have impaired PAS scores relative to females (odds ratio [OR] = 3.5; P = .01).

CONCLUSIONS

Entrance of ingested material into the airway observed during videofluoroscopy is uncommon in healthy adults, which helps support the notion that aging may not directly correlate with increased risk of aspiration. Rather, the increased risk of aspiration observed in the aging population may result from the increased incidence of neurological and other diseases with dysphagia as common sequelae with advancing age. Future investigations should compare age-matched healthy controls with a diseased population (eg, cerebral vascular accident) to further explore the relationship between aspiration risk as a function of age compared to consequence of disease/injury.

Medication swallowing difficulties in people without dysphagia

ABSTRACT Objective: to assess the difficulty in swallowing medications and correlate it with age and gender in healthy adults and elderly. Methods: a total of 439 asymptomatic healthy volunteers (270 females and 169 males), who were not taking any medication on a regular basis, aged from 20 to 84 years, were questioned as for dysphagia, by using the Eating Assessment Tool (EAT-10). Question number five of the EAT-10, specifically, approached the difficulty in swallowing drugs, considering zero as “no swallowing problem” and 1 to 4 as “some degree of difficulty” (4 as great difficulty).The chi-square test (x2) was used for the statistical analysis. Results: a total of 365 (83%) volunteers reported having no difficulty in swallowing medications (89% of men and 80% of women), whereas 74 (17%) reported some degree of difficulty (11% of men and 20% of women)(p = 0.01). These represented 20% of those aged between 20 and 49, and 9% of those aged 50 and over (p = 0.02). Conclusion: in this study, it was observed that both age and gender influence on medication swallowing, a difficulty more frequent among women and young adults. Some degree of difficulty was reported by 17% of the volunteers.

Potentially Inappropriate Prescribing of Oral Solid Medications in Elderly Dysphagic Patients

Pharmaceutical formulations suitable for dysphagic patients are not always commercially available, motivating caregivers to crush tablets or open capsules to facilitate swallowing. Since this action may modify the characteristics of the medicine, it should be considered potentially inappropriate. This paper is the first to focus on how hospitalization affected the rate of potentially inappropriate prescriptions (PIPs) and the incidence of dosage form-related PIPs in elderly patients with dysphagia. Data was collected by reviewing patient medical records in the Italian National Research Center on Aging of Ancona. The therapy at admission and discharge was analysed in terms of: inappropriate drug associations, inappropriate drugs for dysphagic patients, inappropriate dosage forms and inappropriate dosage form modifications. Forty-one dysphagic patients with an average age of 88.3 years were included in the study and 451 prescriptions were analysed. PIPs were widespread at admission, and hospitalization did not improve the situation in a statistically significant manner. The most common PIPs identified (>80%) were related to dosage form selection and modification. This study highlights a clear need for continuing medical education about prescription appropriateness and modification of solid dosage forms in patients with dysphagia.

Palatal augmentation prosthesis (PAP) can improve swallowing function for the patients in rehabilitation hospital

PURPOSE

The aim of this study was to clarify the effects of fitting palatal augmentation prosthesis (PAP) on the swallowing function for the patients in rehabilitation hospital.

METHODS

The subjects included 18 elderly hospitalized patients whose body mass index was <18.5kg/m². All subjects wore maxillary complete denture. During a videofluoroscopic examination in which the patients were asked to swallow, post-swallowing pyriform sinus residue was detected. The subjects' maxillary dentures were then modified into PAPs by recording tongue movement in the palatal region. The resulting swallowing dynamics were evaluated qualitatively and quantitatively before and after fitting the PAP.

RESULTS

We found that fitting the PAP resulted in the resolution of aspiration in two patients and disappearance of pharyngeal residue in three. The pharyngeal delay and transit times were significantly shortened.

CONCLUSIONS

These results demonstrated that PAPs could be beneficial treatment devices that may reduce post-swallowing pharyngeal residue formation due to decreased muscle strength.

Pharyngeal swallowing in older adults: Kinematic analysis using three-dimensional dynamic computed tomography

OBJECTIVES

To assess the effect of age on swallowing with a focus on structural movement, timing and duration of physiologic events.

DESIGN

Cross-sectional study.

SETTING

Tertiary University Medical Center.

PARTICIPANTS

Community-dwelling adults (3 age groups): younger 20 to 39 (n = 23; mean 32 ± 5), middle-aged 40 to 59 (n = 29; mean 49 ± 5) and older adults 60 to 74 (n = 15; mean 67 ± 5).

INTERVENTION

One 10-mL honey-thick liquid (1700 mPa) swallow was studied using 320-row area detector computed tomography scanning.

MEASUREMENTS

Kinematic analysis was performed for each swallow including temporal characteristics and structural movements.

RESULTS

The duration of velopharyngeal closure and laryngeal closure (including epiglottis inversion, laryngeal vestibule closure, true vocal cord closure) was significantly different by age group (P = 0.002, P < 0.001, P = 0.017, P = 0.041, respectively). Events were prolonged in older adults compared with middle-aged and younger adults. The pharyngeal phase was longer for older adults. Velopharyngeal closure started earlier and continued until after complete UES opening. In younger adults, velopharyngeal and laryngeal opening occurred before complete UES opening. No differences were found in bolus movement through the oropharynx by group.

CONCLUSION

During swallowing, older adults had a longer pharyngeal phase characterised by prolonged velopharyngeal and laryngeal closure. This difference may be a protective mechanism to compensate for age-related weakness. A better understanding of the mechanism by which this adaptation occurs is needed to tailor rehabilitation strategies and to maintain swallowing function during the lifespan.

Swallowing Kinematic Differences Across Frozen, Mixed, and Ultrathin Liquid Boluses in Healthy Adults: Age, Sex, and Normal Variability

PURPOSE

The aim of this study was to examine the effects of frozen and mixed-consistency boluses on the swallowing physiology of younger and older adults. We also aimed to quantify factors that lead to increased variability in swallowing outcomes (i.e., age, sex, bolus type).

METHOD

Forty-one healthy adults (18-85 years old) swallowed 5 blocks of 5 different boluses: 10-ml ultrathin liquid, a teaspoon of iced barium, a teaspoon of room-temperature pudding, a teaspoon of frozen pudding, and ultrathin barium with chocolate chips. All data were recorded with videofluoroscopy and underwent detailed timing kinematic measurements.

RESULTS

Neither barium ice nor frozen pudding sped up swallow responses. Many healthy adults initiated swallowing with the bolus as deep as the pyriform sinuses. Swallowing temporal kinematics for ultrathin liquid consistencies are most different from all others tested, requiring the best possible physiological swallowing performance in younger and older healthy individuals (i.e., faster reaction times, longer durations) compared with other bolus types tested. In each measure, older adults had significantly longer durations compared with the younger adults. More variability in swallowing kinematics were seen with age and laryngeal vestibule kinematics.

CONCLUSION

This study provides important contributions to the literature by clarifying normal variability within a wide range of swallowing behaviors and by providing normative data from which to compare disordered populations.

Dysphagia risk, low muscle strength and poor cognition predict malnutrition risk in older adults athospital admission

BACKGROUND

Malnutrition in patients admitted to hospital may have detrimental effects on recovery and healing. Malnutrition is preceded by a state of malnutrition risk, yet malnutrition risk is often not detected during admission. The aim of the current study was to investigate the magnitude and potential predictors of malnutrition risk in older adults, at hospital admission.

METHODS

A cross-sectional was study conducted in 234 older adults (age ≥ 65 or ≥ 55 for Māori or Pacific ethnicity) at admission to hospital in Auckland, New Zealand. Assessment of malnutrition risk status was performed using the Mini Nutritional Assessment Short-Form (MNA®-SF), dysphagia risk by the Eating Assessment Tool (EAT-10), muscle strength by hand grip strength and cognitive status by the Montreal Cognitive Assessment (MoCA) tool.

RESULTS

Among 234 participants, mean age 83.6 ± 7.6 years, 46.6% were identified as at malnutrition risk and 26.9% malnourished. After adjusting for age, gender and ethnicity, the study identified [prevalence ratio (95% confidence interval)] high dysphagia risk [EAT-10 score: 0.98 (0.97-0.99)], low body mass index [kg/m²: 1.02 (1.02-1.03)], low muscle strength [hand grip strength, kg: 1.01 (1.00-1.02)] and decline in cognition [MoCA score: 1.01 (1.00-1.02)] as significant predictors of malnutrition risk in older adults at hospital admission.

CONCLUSION

Among older adults recently admitted to the hospital, almost three-quarters were malnourished or at malnutrition risk. As the majority (88%) of participants were admitted from the community, this illustrates the need for routine nutrition screening both at hospital admission and in community-dwelling older adults. Factors such as dysphagia, unintentional weight loss, decline in muscle strength, and poor cognition may indicate increased risk of malnutrition.

A review of swallow timing in the elderly

Many studies evaluate dysphagia in elderly patients and compare their swallowing to younger controls to assess the degree of swallowing impairment. Previous research suggests that changes should be expected in swallowing due to aging, and these changes need to be considered when performing swallowing assessments. A systematic review was conducted to elucidate the timing of swallowing in healthy. A comprehensive multiengine literature search was conducted to find articles studying swallowing in the healthy elderly, which yielded 22,852 articles of which 11 were judged to be relevant. Only articles using videofluoroscopy as an assessment method for swallowing timing were included. The articles underwent detailed review for study quality and data extraction. The eleven studies contained data for 32 different parameters, and 10 of the 11 studies compared elderly subjects to a younger group. Timing measures from the studies were compiled for analysis. In general, bolus transit times do not appear to change with age. Of note, elderly subjects tended to have a significantly delayed swallow response times and longer duration of upper esophageal sphincter opening. Results showed a large degree of variability across studies for each of the timing measures. Confidence intervals for timing in healthy older participants were computed across studies. Potential sources of variation were identified, including methodological, stimulus-related and participant-related sources. The results suggests that aging affects only a few very specific swallowing timing parameters, and many parameters appear to be unaffected by aging. Therefore, significant differences from a young reference sample should be interpreted as dysphagia rather than normal changes due to aging.

Effects of remifentanil on pharyngeal swallowing: A double blind randomised cross-over study in healthy volunteers

BACKGROUND

Exposure to remifentanil increases the incidence of pulmonary aspiration in healthy volunteers. This effect may be explained by impairment of airway defence mechanisms and/or altered swallowing function. Pressure-flow analysis is a technique that allows objective assessment of swallowing based on pressure-impedance patterns recorded during bolus swallowing.

OBJECTIVES

The aim of this study was to use pressure-flow analysis to quantify the effect of remifentanil on healthy pharyngeal swallowing and to compare these effects with morphine.

DESIGN

A double-blind, randomised, cross-over study.

SETTING

A tertiary care teaching hospital.

VOLUNTEERS

Eleven young volunteers (mean age, 23 years) and seven older volunteers (mean age, 73 years).

INTERVENTIONS

Volunteers were studied twice and received either a target-controlled remifentanil infusion (target concentrations: young, 3 ng ml; old, 2 ng ml) or a bolus injection of morphine (dose: young, 0.1 mg kg; old, 0.07 mg kg). Pharyngeal pressure and impedance were recorded with an indwelling catheter while swallowing 10 boluses of liquid during each measuring phase. Variables defining swallowing function were calculated and compared to determine drug effects.

MAIN OUTCOME MEASURES

Pharyngeal pressure-flow variables following remifentanil exposure.

RESULTS

Changes produced by remifentanil in the measured variables were consistent with greater dysfunction of swallowing. Both the strength of the pharyngeal contractions and pharyngeal bolus propulsion were reduced, whereas flow resistance was increased. The swallow risk index, a global index of swallowing dysfunction, increased overall. At the experimental doses tested, morphine produced similar, but less extensive effects on swallowing.

CONCLUSION

Remifentanil induced dysfunction of the pharyngeal swallowing mechanism. This may contribute to an increased risk of aspiration.

TRIAL REGISTRATION

NCT01924234 (www.clinicaltrials.gov).

Continuum theory: presbyphagia to dysphagia? Functional assessment of swallowing in the elderly

OBJECTIVES

To investigate whether disclosed symptoms (coughing, choking and throat clearing) can be used as early predictors of swallowing disorders in non-hospitalized elderly population. In addition, to determine the presence of early findings of swallowing disorders through fiber optic endoscopic evaluation of swallowing (FEES).

MATERIALS AND METHODS

One hundred subjects older than 60 years were recruited from local community social meetings for seniors, they fulfilled inclusion criteria, and were given an oral interview and underwent FEES, with findings classified as: (1) saliva stasis; (2) pharyngeal residue; (3) penetration; (4) aspiration; (5) laryngeal sensitivity.

RESULTS

Twenty-one percent of subjects declared previous choking, 10% coughing, and 7% throat clearing, 39% had pharyngeal residue; 6% saliva stasis; 9% penetration; 2% aspiration; and 92% laryngeal sensitivity present. Thirty-three percent showed pharyngeal residue without saliva stasis, while only 6% showed positivity for both (p = 0.003).

CONCLUSIONS

Our data suggest that health care professionals should be aware that among an apparently healthy population, some subjects may have swallowing disorders without clinical complaints and that a nasolaryngoscopy exam may not be enough to predict dysphagia. We suggest that FEES should be performed to look for surrogate of dysphagia such as pharyngeal residue, laryngeal penetration, and aspiration.

Indicators of Dysphagia in Aged Care Facilities

PURPOSE

The current cross-sectional study aimed to investigate risk factors for dysphagia in elderly individuals in aged care facilities.

METHOD

A total of 878 individuals from 42 aged care facilities were recruited for this study. The dependent outcome was speech therapist-determined swallowing function. Independent factors were Eating Assessment Tool score, oral motor assessment score, Mini-Mental State Examination, medical history, and various functional status ratings. Binomial logistic regression was used to identify independent variables associated with dysphagia in this cohort.

RESULTS

Two statistical models were constructed. Model 1 used variables from case files without the need for hands-on assessment, and Model 2 used variables that could be obtained from hands-on assessment. Variables positively associated with dysphagia identified in Model 1 were male gender, total dependence for activities of daily living, need for feeding assistance, mobility, requiring assistance walking or using a wheelchair, and history of pneumonia. Variables positively associated with dysphagia identified in Model 2 were Mini-Mental State Examination score, edentulousness, and oral motor assessments score.

CONCLUSIONS

Cognitive function, dentition, and oral motor function are significant indicators associated with the presence of swallowing in the elderly. When assessing the frail elderly, case file information can help clinicians identify frail elderly individuals who may be suffering from dysphagia.

Complications and Mortality Following One to Two-Level Anterior Cervical Fusion for Cervical Spondylosis in Patients Above 80 Years of Age

STUDY DESIGN

A retrospective database review.

OBJECTIVE

The aim of this study was to determine the complication and mortality rates in patients 80 years of age and older who were treated with anterior cervical fusion surgery and to compare these rates against those of other elderly patients.

SUMMARY OF BACKGROUND DATA

Cervical spondylosis is frequently observed in the elderly and is the most common cause of myelopathy in older adults. With increasing life expectancies, a greater proportion of patients are being treated with spine surgery at a later age. Limited information is available regarding outcomes following anterior cervical fusion surgery in patients 80 years of age or older.

METHODS

Medicare data from the PearlDiver Database (2005-2012) were queried for patients who underwent primary one to two-level anterior cervical spine fusion surgeries for cervical spondylosis. After excluding patients with prior spine metastasis, bone cancer, spine trauma, or spine infection, this cohort was divided into two study groups: patients 65 to 79 (51,808) and ≥80 years old (5515) were selected. A cohort of matched control patients was selected from the 65 to 79-year-old and 90-day complication rates and 90-day and 1-year mortality rates were compared between cohorts.

RESULTS

The proportion of patients experiencing at least one major medical complication was relatively increased by 53.4% in patients aged ≥80 years [odds ratio (OR) 1.63]. Patients 80 years of age or older were more likely to experience dysphagia (OR 2.16), reintubation (OR 2.34), and aspiration pneumonitis (OR 3.17). Both 90-day (OR: 4.34) and 1-year (OR 3.68) mortality were significantly higher in the ≥80 year cohort.

CONCLUSION

Patients 80 years of age or older are more likely to experience a major medical complication or mortality following anterior cervical fusion for cervical spondylosis than patients 65 to 79 years old. Dysphagia, aspiration pneumonitis, and reintubation rates are also significantly higher in patients 80 years of age or older. Although complication rates may be higher in this patient population, carefully selected patients could potentially derive much benefit from surgery and should not be screened out solely on the basis of age.

LEVEL OF EVIDENCE

4.

Effects of Age on Esophageal Motility: Use of High-resolution Esophageal Impedance Manometry

Background/Aims

Disturbances of esophageal motility have been reported to be more frequent the aged population. However, the physiology of disturbances in esophageal motility during aging is unclear. The aim of this study was to evaluate the effects of age on esophageal motility using high-resolution esophageal impedance manometry (HRIM).

Methods

Esophageal motor function of 268 subjects were measured using HRIM in 3 age groups, < 40 years (Group A, n = 32), 40–65 years (Group B, n = 185), and > 65 years (Group C, n = 62). Lower esophageal sphincter (LES) and upper esophageal sphincter (UES) pressures, integrated relaxation pressure, distal contractile integral, contractile front velocity, distal latency, and pressures and duration of contraction on 4 positions along the esophagus, and complete bolus transit were measured.

Results

Basal UES pressure was lower in Group C (P < 0.001) but there was no significant difference in the LES pressure among groups. Contractile duration on position 3 (10 cm from proximal LES high pressure zone) was longer in Group C (P = 0.001), and the contractile amplitude on position 4 (5 cm from proximal LES high pressure zone) was lower in Group C (P = 0.005). Distal contractile integral was lower in Group C (P = 0.037). Contractile front velocity (P = 0.015) and the onset velocity (P = 0.040) was lower in Group C. There was no significant difference in impedance values.

Conclusions

The decrease of UES pressure, distal esophageal motility, and peristaltic velocity might be related with esophageal symptoms in the aged population.

Oral drug therapy in elderly with dysphagia: between a rock and a hard place!

Demographic indicators forecast that by 2050, the elderly will account for about one-third of the global population. Geriatric patients require a large number of medicines, and in most cases, these products are administered as solid oral solid dosage forms, as they are by far the most common formulations on the market. However, this population tends to suffer difficulties with swallowing. Caregivers in hospital geriatric units routinely compound in solid oral dosage forms for dysphagic patients by crushing the tablets or opening the capsules to facilitate administration. The manipulation of a tablet or a capsule, if not clearly indicated in the product labeling, is an off-label use of the medicine, and must be supported by documented scientific evidence and requires the patient's informed consent. Compounding of marketed products has been recognized as being responsible for an increased number of adverse events and medical errors. Since extemporaneous compounding is the rule and not the exception in geriatrics departments, the seriousness and scope of issues caused by this daily practice are probably underestimated. In this article, the potential problems associated with the manipulation of authorized solid oral dosage forms are discussed.

Complication and Reoperation Rates Following Surgical Management of Cervical Spondylotic Myelopathy in Medicare Beneficiaries

STUDY DESIGN

Retrospective database review.

OBJECTIVE

To compare complication and reoperation rates after anterior cervical discectomy and fusion (ACDF), posterior cervical fusion (PCFs), and anterior cervical corpectomy and fusion (ACCF) for cervical spondylotic myelopathy (CSM) using a large national database of Medicare beneficiaries.

SUMMARY OF BACKGROUND DATA

CSM is the most common cause of myelopathy in patients over 55 years and is considered the most common cause of spinal cord dysfunction in the world. Surgical treatment includes ACDF, PCF, or ACCF procedures.

METHODS

The PearlDiver database (2005-2012) was utilized to determine revision rates after surgical treatment of CSM by one of the aforementioned surgical treatments. Specifically, 1 to 2 level ACDF, ACCF, and PCF and 3+ level PCF cohorts were included. Each cohort was stratified by the age of 65 years. Survivorship curves were graphed and compared.

RESULTS

Of the patients younger than 65 years of age, there were 10,557 patients treated with 1 to 2 level ACDF procedures, 1319 patients with 1 to 2 level PCF procedures, 1203 patients with 1 to 2 level ACCF procedures, and 2312 patients treated with 3+ level PCF procedures. Of the elderly patients, 24,310 patients were treated with 1 to 2 level ACDFs, 4776 with 1 to 2 level PCF procedures, 3109 with 1 to 2 level ACCFs, and 7760 with 3+ level PCFs. Patients younger than 65 years of age were significantly more likely to have a reoperation procedure, than those 65 years or older when analyzing ACCF, ACDF, and 3+ level PCF procedures. ACCFs were significantly more likely than ACDFs to require reoperation. Patients treated with PCF were consistently more likely to have nondysphagia-related complications than those treated with ACDF. Rates of transfusion, dysphagia, and hematoma/seroma formation were significantly increased with ACCF compared with ACDF within the elderly population.

CONCLUSION

The elderly are significantly less likely to have a revision surgery after surgical treatment for CSM. Patients treated with ACCF are more likely to need a revision than those treated with ACDF.

LEVEL OF EVIDENCE

3.

Gastrointestinal Dysmotility in the Elderly

The number of persons 60 years and older has increased 3-fold between 1950 and 2000. Aging alone does not greatly impact the gastrointestinal (GI) tract. Digestive dysfunction, including esophageal reflux, achalasia, dysphagia, dyspepsia, delayed gastric emptying, constipation, fecal incontinence, and fecal impaction, is a result of the highly prevalent comorbid conditions and the medications with which those conditions are treated. A multidisciplinary approach with the expertise of a geriatrician, gastroenterologist, neurologist, speech pathologist, and physical therapist ensures a comprehensive functional and neurological assessment of the older patient. Radiographic and endoscopic evaluation may be warranted in the evaluation of the symptomatic older patient with consideration given to the risks and benefits of the test being used. Treatment of the digestive dysfunction is aimed at improving health-related quality of life if cure cannot be achieved. Promotion of healthy aging, treatment of comorbid conditions, and avoidance of polypharmacy may prevent some of these digestive disorders. The age-related changes in GI motility, clinical presentation of GI dysmotility, and therapeutic principles in the symptomatic older patient are reviewed here.

European Society for Swallowing Disorders - European Union Geriatric Medicine Society white paper: oropharyngeal dysphagia as a geriatric syndrome

This position document has been developed by the Dysphagia Working Group, a committee of members from the European Society for Swallowing Disorders and the European Union Geriatric Medicine Society, and invited experts. It consists of 12 sections that cover all aspects of clinical management of oropharyngeal dysphagia (OD) related to geriatric medicine and discusses prevalence, quality of life, and legal and ethical issues, as well as health economics and social burden. OD constitutes impaired or uncomfortable transit of food or liquids from the oral cavity to the esophagus, and it is included in the World Health Organization's classification of diseases. It can cause severe complications such as malnutrition, dehydration, respiratory infections, aspiration pneumonia, and increased readmissions, institutionalization, and morbimortality. OD is a prevalent and serious problem among all phenotypes of older patients as oropharyngeal swallow response is impaired in older people and can cause aspiration. Despite its prevalence and severity, OD is still underdiagnosed and untreated in many medical centers. There are several validated clinical and instrumental methods (videofluoroscopy and fiberoptic endoscopic evaluation of swallowing) to diagnose OD, and treatment is mainly based on compensatory measures, although new treatments to stimulate the oropharyngeal swallow response are under research. OD matches the definition of a geriatric syndrome as it is highly prevalent among older people, is caused by multiple factors, is associated with several comorbidities and poor prognosis, and needs a multidimensional approach to be treated. OD should be given more importance and attention and thus be included in all standard screening protocols, treated, and regularly monitored to prevent its main complications. More research is needed to develop and standardize new treatments and management protocols for older patients with OD, which is a challenging mission for our societies.

Wearing complete dentures is associated with changes in the three-dimensional shape of the oropharynx in edentulous older people that affect swallowing

OBJECTIVE

To investigate the effects of wearing complete dentures on pharyngeal shape for swallowing in edentulous older people.

BACKGROUND

In the absence of complete dentures, edentulous older people often lose the occlusal support necessary to position the mandible, which leads to an anterosuperior shift of the mandible during swallowing. This may result in pharyngeal shape changes effecting swallowing function in older people. However, the details of this phenomenon are currently unclear.

MATERIALS AND METHODS

Participants were 17 older edentulous volunteers. Cone-beam computed tomography imaging was performed with the participant in the seated position and wearing (i) both maxillary and mandibular dentures, (ii) maxillary dentures only and (iii) no dentures. During imaging, participants were instructed to keep their mouth closed to the mandibular position determined in advance during swallowing for each denture-wearing condition. The volume, height and average cross-sectional area of the velopharynx and oropharynx were measured, and the positions of the epiglottis and mandible were recorded.

RESULTS

While the vertical height of the oral cavity and pharynx significantly decreased, the volume and average cross-sectional area of the oropharynx significantly increased when dentures were not worn (p < 0.01). The absence of dentures caused an anterosuperior shift of the mandible when swallowing and drew the epiglottis forward, resulting in expansion of the oropharynx where the tongue base forms the anterior wall.

CONCLUSION

The absence of dentures results in anatomical changes in oropharyngeal shape that may exacerbate the pharyngeal expansion caused by ageing and reduce the swallowing reserve.

European Society for Swallowing Disorders - European Union Geriatric Medicine Society white paper: oropharyngeal dysphagia as a geriatric syndrome

This position document has been developed by the Dysphagia Working Group, a committee of members from the European Society for Swallowing Disorders and the European Union Geriatric Medicine Society, and invited experts. It consists of 12 sections that cover all aspects of clinical management of oropharyngeal dysphagia (OD) related to geriatric medicine and discusses prevalence, quality of life, and legal and ethical issues, as well as health economics and social burden. OD constitutes impaired or uncomfortable transit of food or liquids from the oral cavity to the esophagus, and it is included in the World Health Organization's classification of diseases. It can cause severe complications such as malnutrition, dehydration, respiratory infections, aspiration pneumonia, and increased readmissions, institutionalization, and morbimortality. OD is a prevalent and serious problem among all phenotypes of older patients as oropharyngeal swallow response is impaired in older people and can cause aspiration. Despite its prevalence and severity, OD is still underdiagnosed and untreated in many medical centers. There are several validated clinical and instrumental methods (videofluoroscopy and fiberoptic endoscopic evaluation of swallowing) to diagnose OD, and treatment is mainly based on compensatory measures, although new treatments to stimulate the oropharyngeal swallow response are under research. OD matches the definition of a geriatric syndrome as it is highly prevalent among older people, is caused by multiple factors, is associated with several comorbidities and poor prognosis, and needs a multidimensional approach to be treated. OD should be given more importance and attention and thus be included in all standard screening protocols, treated, and regularly monitored to prevent its main complications. More research is needed to develop and standardize new treatments and management protocols for older patients with OD, which is a challenging mission for our societies.

Effects of age and non-oropharyngeal proprioceptive and exteroceptive sensation on the magnitude of anticipatory mouth opening during eating

To best prevent and treat eating/swallowing problems, it is essential to understand how components of oral physiology contribute to the preservation and/or degradation of eating/swallowing in healthy ageing. Anticipatory, pre-swallow motor movements may be critical to safe and efficient eating/swallowing, particularly for older adults. However, the nature of these responses is relatively unknown. This study compared the magnitude of anticipatory mouth opening during eating in healthy older (aged 70-85) and younger (aged 18-30) adults under four eating conditions: typical self-feeding, typical assisted feeding (being fed by a research assistant resulting in proprioceptive loss), sensory loss self-feeding (wearing blindfold/headphones resulting in exteroceptive loss) and sensory loss assisted feeding (proprioceptive and exteroceptive loss). Older adults opened their mouths wider than younger adults in anticipation of food intake under both typical and most non-oropharyngeal sensory loss conditions. Further, the loss of proprioceptive and exteroceptive cues resulted in decreased anticipatory mouth opening for all participants. Greater mouth opening in older adults may be a protective compensation, contributing to the preservation of function associated with healthy ageing. Our finding that the loss of non-oropharyngeal sensory cues resulted in decreased anticipatory mouth opening highlights how important proprioception, vision, and hearing are in pre-swallow behaviour. Age- and disease-related changes in vision, hearing, and the ability to self-feed may reduce the effectiveness of these pre-swallow strategies.

Effects of laryngeal restriction on pharyngeal peristalsis and biomechanics: Clinical implications

To date, rehabilitative exercises aimed at strengthening the pharyngeal muscles have not been developed due to the inability to successfully overload and fatigue these muscles during their contraction, a necessary requirement for strength training. The purpose of this study was to test the hypothesis that applying resistance against anterosuperior movement of the hyolaryngeal complex will overload the pharyngeal muscles and by repetitive swallowing will result in their fatigue manifested by a reduction in pharyngeal peristaltic amplitude. Studies were done in two groups. In group 1 studies 15 healthy subjects (age: 42 ± 14 yr, 11 females) were studied to determine whether imposing resistance to swallowing using a handmade device can affect the swallow-induced hyolaryngeal excursion and related upper esophageal sphincter (UES) opening. In group 2, an additional 15 healthy subjects (age 56 ± 25 yr, 7 females) were studied to determine whether imposing resistance to the anterosuperior excursion of the hyolaryngeal complex induces fatigue manifested as reduction in pharyngeal contractile pressure during repeated swallowing. Analysis of the video recordings showed significant decrease in maximum deglutitive superior laryngeal excursion and UES opening diameter (P < 0.01) due to resistive load. Consecutive swallows against the resistive load showed significant decrease in pharyngeal contractile integral (PhCI) values (P < 0.01). Correlation analysis showed a significant negative correlation between PhCI and successive swallows, suggesting "fatigue" (P < 0.001). In conclusion, repeated swallows against a resistive load induced by restricting the anterosuperior excursion of the larynx safely induces fatigue in pharyngeal peristalsis and thus has the potential to strengthen the pharyngeal contractile function.

Fork test: A new simple and reliable consistency measurement for the dysphagia diet

The objective of this study was to validate fork test which is a simple tool to assess the consistency of food. The consistencies of 27 water and thickener mixtures were measured with a viscometer. These measures were then compared to those obtained with fork test to evaluate the validity of fork test. The inter-observer and intra-observer reliabilities of the fork test were assessed with an intra-class correlation coefficient. The viscometer was used to obtain reference values for three categories (0-300 cP, 300-10,000 cP, and >10,000 cP) in order to categorize water and thickener mixtures into grade 1, grade 2, or grade 3 according to the results of fork test. Our results revealed that the fork test showed excellent validity (r = -0.889, p < 0.05), intra-observer reliability, and inter-observer reliability. Therefore, fork test may be used as a practical tool to assess food consistency.

Pressure topography metrics for high-resolution pharyngeal-esophageal manofluorography-a normative study of younger and older adults

BACKGROUND

We aimed to define normative values for novel pressure topography metrics for high-resolution pharyngeal-esophageal manofluorography. The effects of age, gender, and bolus properties were examined.

METHODS

Concurrent high-resolution manometry (HRM) and videofluoroscopy data were collected from 22 younger (aged 21-40) and 22 older (aged 60-80) healthy subjects. Pressure topography was analyzed by correlating pressure domains with videofluoroscopic events. Nine pressure topography metrics of the pharyngeal and proximal esophageal swallow were extracted; four of these were also compared with previously obtained esophageal HRM studies to assess the effects of catheter diameter.

KEY RESULTS

Older individuals exhibited more vigorous contractility in the pharynx than did younger subjects with all bolus types, but the greatest values for both groups were with effortful swallow and on that measure the age groups were similar. Upper esophageal sphincter (UES) intrabolus pressure during sphincter opening was also greater in the older subjects. Some gender differences were observed, particularly related to proximal esophageal contractile vigor. Bolus consistency had no consistent effect. Studies using the larger catheter diameter resulted in significantly greater contractile vigor in the UES and proximal esophagus.

CONCLUSIONS & INFERENCES

Older adults exhibited more vigorous pharyngeal contractions than young adults, albeit within a similar range of capacity, perhaps reflecting a compensatory response to other age-related physiological changes. Greater UES intrabolus pressures observed during bolus transit in the older group likely reflect reduced UES compliance with age. Normative data on novel HRM metrics collected in this study can serve as a reference for future clinical studies.

Comparison of maximal tongue strength and tongue strength used during swallowing in relation to age in healthy adults

[Purpose] The aim of this study was to measure and compare the maximal tongue strength and tongue strength used during swallowing in young and older adults. [Subjects and Methods] The study recruited 80 healthy young (aged 20 to 39 years) and older adults (aged ≥65 years) in public places. The Iowa Oral Performance Instrument was used to measure maximal tongue strength and tongue strength used during swallowing. For each subject, the peak value of three measurements was recorded and analyzed. [Results] Maximal tongue strength was statistically significantly higher for the young adults group than the older adults group. Conversely, tongue strength used during swallowing was statistically significantly higher for the older adults group than the young adults group. The percentages of tongue strength used during swallowing for the young adults and older adults groups were approximately 38.8% and 53.8%, respectively. [Conclusion] This study confirmed that older adults have a lower maximal tongue strength than young adults, but a higher tongue strength used during swallowing.